Traditional Chinese Medicine Pulse Diagnosis, Manual Pulse Diagnosis

The testing of classical pulse concepts in Chinese medicine: left right hand pulse strength discrepancy between gender and its clinical implications Emma King Clinical tutor Sean Walsh Lecturer Deirdre Cobbin Senior Lecturer College of Traditional Chinese Medicine, Department of Health Sciences, Faculty of Science University of Technology, Sydney Australia Correspondence: [email protected] [email protected] PO Box 123 Broadway NSW 2007 Australia 1. Abstract The use of the radial pulse as a diagnostic tool is an important part of the Chinese medicine (CM) clinical evaluation. In spite of its long history of use, there is little systematic information available to support the many claims about the relationship between the pulse concepts contained in the classical Chinese texts and their manifestation in contemporary clinical practice. This study reports the findings of an investigation into inter-arm pulse strength differences in subjects and the relationship to traditional pulse claims relating to gender. The pulses were assessed by two pulse assessors with a demonstrated high level of inter-rater agreement using a reliable means of measuring and recording pulse characteristics. This was achieved by reporting on the physical sensations that are detected under the fingertips that had been determined as relating to the concept of gender related left/right force/strength differences in the relevant available literature Using a standardised pulse taking procedure and concrete operational definitions two pulse assessors each assessed the overall left and right pulse strength and rated their findings on a standardised pulse form. The overall percentage inter-rater agreement for manual assessment of dominant hand was 86% (based on a cohort of 66 subjects). A further breakdown of the findings indicated inter-rater agreement for 81% of male subject pulses and 89% of female subject pulses. In relation to the three possible choices regarding dominant side (right, neither, left) the right hand side was most commonly selected as relatively strongest of the two regardless of gender (60% of males and 71% of females). Analysis of the data using Chi square (II) found that the observed frequencies for an assessor’s rating of dominant hand in males were significantly different to that as expected according to CM theory. Accordingly, the CM assumption of gender related differences in left and right hand pulses was not supported within this study. Key Words Radial pulse, gender differences, traditional Chinese medicine, TCM, pulse diagnosis, inter-rater reliability, diagnostic techniques 2. Introduction For over two thousand years, in Europe, the Middle East and Orient there has been an interest in the relationship of the radial arterial pulses to an individual’s health and response to disease. Early pioneers of pulse diagnosis include the Chinese physician Wang Shu-he (Jin Dynasty), Galen (129-195 AD) from ancient Greece and Susruta (5th Century BC) of the Ayurvedic traditions of India. Within the context of Chinese medicine (CM), the term ‘pulse diagnosis’ is used to refer primarily to palpation of the radial artery but also encompasses the Nine Continent Pulses, a seldom used technique involving palpation and comparison of various arterial pulses around the body. Interpretation of the pulse in terms of health depends on a complex system of qualities and theories that have developed over the past 1800 years and that link changes in arterial characteristics and blood flow to both health and pathology, taking into account circadian rhythms, an individual’s environment and personal traits. While not unique to CM, the pulse does take on special significance in CM diagnosis. It is used as an indicator of the functional activity for both cardiac and non-cardiac organ structures including functional relationships between organ groupings. The underlying assumption of pulse diagnosis is the ability of the pulse to reflect and change with the relative state of health of the body. For example, if the liver were inflamed or the spleen hypo functioning, the subsequent changes in the haemodynamics of the arterial system would be reflected in the arterial pulses. That is, the pulse is viewed as a reflection of function rather than an indication of the physiological integrity of an organ entity. Other intrinsic claims associated with CM pulse diagnosis concern its value as an indicator of the integrity of the immune system and for prognosis. Veith highlights the emphasis traditionally placed upon pulse diagnosis in that all other methods of determining disease are only subsidiary to palpation and used mainly in connection with it (p. 42). For this reason pulse diagnosis is often described as the most important of the CM diagnostic processes (Kaptchuk, 2000). In spite of the historical importance and continued reiteration of its crucial role in the diagnostic process in many contemporary CM texts, many of the underlying assumptions and concepts that underpin pulse as a clinically useful technique have not been clinically substantiated. The paucity of evidence means that long held and untested assumptions are taken as clinical fact even though no independent evidence has been gathered to either support or refute their validity within the actual pulse physiology. 3. One such assumption is the gender based difference in palpable strength between the left and right radial pulses. The pulse is said to be stronger on the left hand side for males relative to their right, and for females, stronger on the right hand side relative to their left. Also, the Chi position should be stronger in women and the Cun position stronger in men relative to the other respective pulse positions (Maciocia, 1989). Clinically, a normal left /right imbalance in the pulse strength for a female would be deemed pathological if presenting in a male and therefore require treatment to rectify this imbalance. If pathology is not present then it is viewed as a prognostic sign of disharmony and impending poor health (Rogers, 1997). In an examination of both classical and contemporary CM texts, there is a changing emphasis on the importance of gender influence on pulse. For example, the Nan Ching (Classic of Difficult Issues, 2nd century CE) states that male pulses are stronger above the ‘gate’, that is the Cun position relative to the Chi position, and for females, the pulse is relatively stronger below the ‘gate’, that is, the Chi position (19th difficult issue - p. 44-45, Flaws, 1999; p. 259, Unschuld, 1986). The Mai Jing (Pulse Classic), has two references to pulse strength regarding gender, both reiterate that the left side should be stronger in males and the right side in females relative to the other side. In another classical TCM text, the Bin Hu Mai Xue (Lakeside Master’s Study of the Pulse), the gender related strength difference is reaffirmed in which it states that left large is auspicious (or normal) for a man. Right large is auspicious for a woman (p. 9, Li, 1998). In Huynh’s (1981) translation of the Bin Hu Mai Xue, an explanatory note is provided for the justification of a gender related strength difference between sides. ‘The left is yang and the right is yin. Men have more yang qi. So, provided their qi is well regulated, their left hand pulse is stronger. Women have more yin blood. So, provided their qi is well regulated, their right hand pulse is stronger’ (p. 4). However, in some contemporary CM texts, gender specificity in relation to pulse strength differences between right and left sides appears to be largely abandoned, with most referring to overall differences in strength between genders. For example, in adult females, the pulse is usually softer and weaker than the male (p. 37, Lu, 1996); Women’s pulse are slightly softer and slightly quicker than men’s (p. 28 O’Connor and Bensky, 1981). On the other hand, contemporary CM texts in the West tend to reiterate both the ‘contemporary Chinese view’ as well as traditional theory regarding gender based left/right differences. For example, Hammer (2001) quoting his own experience states that the pulse is normally somewhat stronger on the 4. right side in women, and on the left side in men (p. 95). Rogers states that the pulses of a women should be a little stronger on the right wrist, while those of a man should be stronger on the left (p. 88, 2000). Maciocia (p. 166, 1989) similarly notes a gender related left/right strength discrepancy. While not in reference to any specific difference in pulse force, interestingly, Morant (1994) refers to the left as representing ‘blood/husband’ and the right ‘nervous energy/wife’ (p. 300). In their examination of the use of the pulse across cultures, Amber and Babey–Brooke (1966) noted that the left side is positive and the right side is negative in the male; the right side positive and the left side negative in the female (p.148). In the absence of further clarification, it is assumed that this refers to comparative strength or force. In some pulse assumption systems, a left/right strength discrepancy is related to the relative balance between Qi and Blood: the left side pulse relates to blood and the right side pulse to Qi, regardless of gender (reference). Applying this concept to a subject’s gender, if men are relatively stronger on the left, then logic dictates that they are constantly Qi vacuous. For women, this would manifest as a constant state of Blood vacuity. However, if the pulse situation was reversed, then each genders respective pulse would reflect disharmony and impending poor health according to classical gender specific concepts of inter-arm strength differences. Treatment principles for this situation would suggest that the practitioner try and rebalance the pulses to promote optimal health. The practitioner would endeavour then to have the left pulse be stronger for men and the right stronger for women.

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